Going through Insurance?

Almost ALWAYS 100% covered by insurance!

Fill out the form below:

If you have another insurance not listed, payment is out of pocket and we can provide you with a superbill to submit to your insurance. You may have out-of-network benefits for nutritional counseling.

New Client Insurance Contact Form

Client Name

First Name

Last Name

Client Email

Client Phone Number

Country

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Client Date of Birth

Client Pronouns

Reason for seeking nutrition counseling?

Medical Diagnosis

If you are seeking nutrition counseling and plan to use your health insurance, please provide us with a medical health diagnosis as your insurance may require this information:

List your medical diagnosis, if not seen above:

Please Select your insurance carrier:

Primary Care Holder of Plan:

Primary care holder name:

First Name

Last Name

Primary care holder date of birth:

Member ID (please include ALL LETTERS & NUMBERS)

Group number (please include ALL LETTERS & NUMBERS)

Provider Services Phone Number:

Can be found on the back of your insurance card.

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Once submitted, you may access our client portal to book a 1:1 Initial Nutrition Consultation through insurance!

How did you hear about us?

Best time to contact you:

Please read over our mandatory policy:

To schedule an appointment, a credit card is required to reserve your spot. Your credit card will be charged to cover any co-payments, deductibles or any amount insurance does not cover per session), additional non-covered services (group programs, journal reviews, phone calls, responses to nutrition-related messages between sessions, or any late cancellation fee ($50 for no-shows, 10+ minutes late, or less than 48-hours notice to reschedule/cancel).

Yes, I agree to the terms and conditions of the Intuitively Nourished LLC policy.